Household Screener

NSFG OMB Attachment I OMB No. 0920-0314

Form Approved

OMB No. 0920-0314

Exp. Date xx/xx/20xx

Screener Instrument – English

THIS ITALICIZED TEXT CURRENTLY APPEARS ON SCREEN, IN COMPLIANCE WITH OMB GUIDELINES.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (OMB No. 0920-0314)

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the government.

CONFIRMA

 Interviewer checkpoint: 

This is sample ID [Sample ID preload]. You are at: 

[Address number preload], [Street name preload]

[Apartment number preload, if app]
[City name preload], [State where Interview is being conducted preload], [Zip code preload]

       If you have entered the wrong sample line, please suspend this case by pressing [Alt+X] 

       Please re-enter the numeric portion of the address to continue

INFORMANT

 Interviewer checkpoint: 

       Who are you talking to now? 

1.  Household Member
5.  Proxy Reporter

HHPerson[n].NAME

I would like the name (or initials) of the people who usually live here.
Please include any unmarried children away from home living in a dormitory, fraternity or sorority.

Remember that this interview is completely voluntary and confidential.
If there is any question that you do not wish to answer, please let me
know and we can move on to the next question.

Let's start with you, what is your name?/What is the next person’s name?

       ENTER Name 

HHPerson[n].SEX

       If necessary, ask: (Is [Name of nth person in household] male or female?) 

1.  Male
2.  Female

HHPerson[n].AGE_X

How old are you/is [Name of nth person in household]? 

       If necessary, ask: (How old were you/was [Name of nth person in household] on your/his/her last birthday?) 

      Age probes: Is the household member 

            14 or under? If yes, enter [14]. If no, continue; 
            15-17? If yes, enter [16]. If no, continue; 
            18-19? If yes, enter [18]. If no, continue; 
            20-49? If yes, enter [32]. If no, continue; 
            50 or older? If yes, enter [50]. 

       ENTER [0] if less than 1 year 

HHPerson[n].HISP

Do you /does [Name of nth person in household] consider yourself/himself/herself to be Hispanic or Latino? 

[HELP AVAILABLE]

1.  Yes
5.  No

HHPerson[n].RACE [Only if HHPerson[n].HISP = 5]

What race do you/does [Name of nth person in household] consider yourself/himself/herself to be? 

[HELP AVAILABLE]

       READ list: 

1.  American Indian or Alaska Native
2.  Asian
3.  Native Hawaiian or other Pacific Islander
4.  Black or African-American
5.  White

HHPerson[n].DORMRES [Only if HHPerson[n].AGE_X = 17-22]

Do you/does [Name of nth person in household live in a college or university dormitory, 
fraternity, or sorority during the school year? 

1.  Yes
5.  No

EndRoster

Before we finish, are there any other members of this household 
who are currently living in a college or university dormitory, 
fraternity, or sorority? 

       If Informant says there are no others, select the [Continue] button. 

       Otherwise, if Informant has more people to describe, press the [Up-arrow] 
           to return to the roster screen and enter additional household information 

VERROSTER

To ensure I have entered all the information correctly, I would like to review the list of household members with you. Please let me know if any of this information is incorrect. 

Currently I have the following information about this household: 

You're [Name (1)] and you’re [Age(1)] years old and consider yourself to be [Hispanic or Latino/American Indian or Alaska Native/Asian/Native Hawaiian or Other Pacific Islander/Black or African-American/White/F/M]

[Name of the nth person in the household] and he/she is [Age of the nth person in the household] years old and considers himself/herself to be [Hispanic or Latino/American Indian or Alaska Native/Asian/Native Hawaiian or Other Pacific Islander/Black or African-American/White/F/M]

       If there is incorrect information, step back to the roster screen, by pressing the [Up] arrow,
         and enter additional household information 

       ASK if necessary: (What should be changed?) 

       ENTER [Continue] once all information has been verified to be correct 

EXITAGE [Would occur after VERROSTER only if no household member is between the ages of 15 and 49]

Thank you. In this study, we are only interviewing men and women
between the ages of 15 and 49. So, these are all the questions I
have for you now. On behalf of the University of Michigan, the US
Public Health Service, and the US Department of Health and Human
Services, I thank you for taking the time to help with this survey.

(My home office may be calling you to verify that I was at the correct
address and spoke with a household member. For these reasons, may I
have your telephone number?)

 Go To ST_sPhone

EXITSCR1 [If selected member of household is a dorm resident]

Thank you for your time. (RNAME) has been selected to provide additional information for this study. Is (RNAME) currently away at school or college?

1.  Yes
5.  No

EXITSCR2

[If informant is selected]

Thank you for your time. You have been selected for the study. May we begin the interview now?

[If a minor household member is selected]

Thank you for your time. [RNAME] has been selected to provide additional information for this study. May I speak to a parent or guardian of [RNAME] now?

[If a non-minor household member is selected]

Thank you for your time. [RNAME] has been selected to provide additional information for this study. May I speak to [RNAME] now?

1.  Yes
5.  No

ST_sPhone

May I have a telephone number to contact you/[RNAME]?

LANG

 Interviewer checkpoint: 

       Please code the likely interview language. 

1.  English
2.  Spanish
3.  Unknown
4.  Other

SCOBS_2

 Interviewer checkpoint: 

[HELP AVAILABLE]

       Do you think the selected respondent is in an active 
           sexual relationship with an opposite-sex partner? 

1.  Yes
5.  No

SCOBS_3

 Interviewer checkpoint: 

       What is the probability of getting the main interview? 

1.  High
2.  Medium
3.  Low

SCComplete

 Interviewer checkpoint: 

       You have reached the end of the NSFG Screener 

       ENTER [1] to exit interview 

4